Follow appropriate sterile technique according to institutional policy.
Position the patient and operator
Place the patient supine with the head in a neutral position.
Position the operator on the same side as the intended catheter insertion.
Place the transducer
Position the transducer transversely over the vessel, just inferior to the midpoint of the clavicle.
Direct the orientation marker toward the patient’s head, at the 12 o’clock position.
Identify the subclavian vein
Locate the subclavian vein as an anechoic, circular structure just inferior and deep to the clavicle.
Slowly move the transducer approximately 1–2 inches laterally while keeping the transducer face below the clavicle.
Use this position to obtain the best view of the distal subclavian and proximal axillary vein.
Recognize the risk of posterior wall puncture
The lung lies directly posterior to the vessel.
Avoid advancing through the posterior wall of the vein.
Center the vein
Adjust the transducer until the vein is centered in the ultrasound image.
Position the needle just superior to the transducer.
Begin needle insertion
Slowly advance the needle adjacent to the transducer’s center line.
The needle should appear as a small, bright dot in the ultrasound image.
Use the short-axis, dynamic needle-tip technique
When the needle tip becomes visible, slide the transducer a short distance medially until the tip disappears.
Slowly advance the needle until the tip reappears.
Repeat this process to ensure that the needle tip remains under direct ultrasound guidance.
Puncture the vein
Continue advancing the needle slowly until the tip is seen indenting and then puncturing the subclavian or proximal axillary vein.
Take care to avoid posterior wall puncture because of the underlying lung.
Confirm needle position
Rotate the transducer 90° to obtain an in-plane, longitudinal view.
Confirm that the needle tip lies within the midportion of the subclavian/proximal axillary vein.Complete catheter advancement, confirmation, securing, and post-procedure care according to approved local guidelines.
Proceed according to institutional protocol
Complete catheter advancement, confirmation, securing, and post-procedure care according to approved local guidelines.
